9) Maternal Medicine: Neurology Flashcards
(133 cards)
1
Q
Prevalence of epilepsy in pregnancy
A
0.5-1%
2
Q
Percentage of WWE in reproductive age group
A
2/3
3
Q
When can women be considered “no longer epileptic”?
A
If 10 years seizure free (5 of those off medication) or if childhood seizures but have reached adulthood without seizures or treatment.
4
Q
Women with which type of seizures are highest risk for SUDEP
A
Tonic-clinic seizures
5
Q
Rate of congenital malformations in WWE (including on AED)
A
Unmediated: 2.8% (comparable to background risk) Medicated: 4-10% risk - Levetiracetam 1-2% - Lamotrigine 2-5% (Dose dependent) - Carbemazepine 3.4% - Valproate 10% - Polypharmacy 17% 17% risk if previous child affected by AED congenital malformation.
6
Q
Types of congenital malformations
A
Valproate - NTD, orofacial cleft, hypospadias, poor cognition and neurodevelopment (learning difficulties and autism)
Lamotrigine: Cardiac defects + clefts.
Levetiracetam: Cardiac defects + NTD
These have a lower risk of cognitive problems than SV.
Carbamazepine & Phenytoin - Cardiac/Cleft
Phenobarbital - Cardiac
7
Q
When should folic acid be used?
A
5mg 3/12 pre-conception and at least until end of first trimester
8
Q
What proportion of patients will remain seizure free throughout pregnancy?
A
67% seizure free.
As high as 74-92% if seizure free for 9-12m pre-conception.
Generalised seizures 74%, focal seizures 60%.
(17% will have improved control, 17% worsened control)
9
Q
Risk of child having epilepsy
A
4-5% if one parent affected.
15-20% if both parents affected.
10% if previous child affected.
10
Q
Advice re: AED dosing
A
Drug levels likely to fall in pregnancy (lamotrigine can fall by up to 70%). No role for routine level checking but need to consider clinical symptoms and likely increase dose in pregnancy.
11
Q
Which infants should receive vitamin K?
A
Mothers on anti-epileptic drugs - 1mg vitamin K IM.
12
Q
When should WWE be delivered?
A
No indication for early delivery.
13
Q
Risk of seizure intrapartum
A
1-2% risk in labour
1-2% risk in first 24 hours postpartum
(Overall risk 3.5%)
14
Q
What can be used prophylactically for women at high risk of seizures in labour?
A
Clobazam orally.
15
Q
What percentage of pregnancies are complicated by status epileptics?
A
1%
16
Q
Management of seizures in pregnancy/labour
A
If IV access: 4mg lorazepam or 5-10mg diazepam.
If no IV access: 10-20mg rectal diazepam, 10mg buccal midazolam.
If not resolving: 10-15mg/kg phenytoin.
If persistent uterine hypertonic - tocolytic.
If not resolved after 5 minutes then expedite delivery.
17
Q
Risk of PND in WWE
A
29%
18
Q
Contraception in WWE
A
If enzyme inducing drug (carbamazepine, phenytoin, topimarate, phenobarbitals, primidone) - either depot or coil (Mirena or copper).
If non-enzyme inducing drug then any method.
Lamotrigine levels are reduced by oestrogen containing contraceptives therefore avoid those or increase dose.
Emergency contraception - if enzyme inducer then copper coil or double dose LNG.
19
Q
In what percentage of pregnancies are AEDs used?
A
1 in 200
20
Q
What percentage of WWE will deliver a healthy baby?
A
96%
21
Q
Risk of mortality in WWE compared to general population
A
10 x higher
60 per 100,000
22
Q
When is fetal harm from AEDs highest?
A
1st trimester for congenital malformations. 3rd trimester for cognitive impairment.
23
Q
Risk of SGA in WWE taking AEDs
A
2 x higher
24
Q
Other risks of epilepsy in pregnancy
A
Miscarriage APH Hypertension IOL CS PTB PPH
25
Which are the first line AEDs in people with generalised epilepsy syndromes?
Lamotrigine and Levetiracetam
26
Breastfeeding in epilepsy
Yes!
27
What is SUDEP?
Death unrelated to trauma/drowning/status epileptics.
| Main cause of death in WWE.
28
Incidence of SUDEP
On Lamotrigine: 2.5 per 1000 pt years
| On other AEDs: 0.5-1 per 1000 pt years
29
In SCI, percentage of worsening spasticity?
12%
30
In SCI, treatment of spasticity
Intrathecal baclofen
| Oral oxybutynin can be used for bladder spasms
31
What percentage of women with SCI conceive post injury?
14%
32
At what level of SCI is a ventilation assessment in pregnancy advised?
```
Above T4
(Vital capacity <12-15ml/kg requires mechanical ventilation)
```
33
At what level of SCI is there a risk of autonomic dysreflexia?
Above T6
34
At what level of SCI is there a risk of late PTL, altered perception of FM and inability to feel labour pains?
Above T10
35
What percentage of patients with SCI have PTL?
15%
36
At what level of SCI is there an increased risk of malpresentation?
Above T12
37
Above what level of SCI is there a risk of scarring in epidural space affecting analgesia?
Above L2-L4
38
What percentage of patients with SCI have their mobility limited further by pregnancy?
4.5%
39
What is the effect of SCI on congenital malformations and stillbirths?
Not increased
40
What is the recommended mode of delivery for patients with SCI?
Vaginal delivery unless concerns re: cephalopelvic disproportion.
- If SCI at young age or pelvic trauma then clinical pelvimetry recommended and likely CS.
41
Is admission recommended in patients with SCI?
Recommended late in 3rd trimester to avoid unattended delivery
42
What is the effect of SCI on VTE risk?
- First 6 months are SCI risk is increased, after this it reverts to normal.
- Score "1" on VTE for immobility in chronic SCI.
43
What happens in autonomic dysreflexia?
Any noxious stimuli below level of lesion isn't modulated by the brain and so sympathetic system goes crazy!
Hypertension --> Vagal stimulation --> Bradycardia
Life threatening.
44
Symptoms of autonomic dysreflexia
Nausea, anxiety, malaise, prickling sensation in skull, ringing in head, throbbing headache.
45
Treatment of autonomic dysreflexia
Removal of noxious stimuli.
| Medical treatment: SL nifedipine, GTN patch/spray, Nitroglycerine ointment, Labetalol/Hydralazine.
46
Who needs an epidural in SCI?
Should be recommended early in labour for people with lesion above T6 to prevent AD.
Can be used as an option for analgesia for others.
47
What level is sensory supply from uterus?
L1-T11
48
What level is cervical dilatation perceived at?
T11/T12
49
Rules for suprapubic catheter and CS
Change catheter in 24 hours prior to surgery
Incision 2cm above suprapubic catheter
Use non-absorbable sutures
50
Breastfeeding in SCI
Yes! Initiation may be delayed if SCI above T4 (may require visual stimulation or oxytocin nasal spray)
51
Risks of spinal cord injury occurring during pregnancy
Increased rates of miscarriage and congenital anomalies (secondary to hypoxia from spinal shock).
Direct trauma to uterus from compression can cause injury.
52
MS is more common in men or women?
2-3 x more common in women
53
Mean age of onset of MS
30 years
54
What proportion of women with MS will develop during their reproductive years?
50%
55
Incidence of MS
1 in 330
56
What percentage of people with MS have an affected family member?
80%
57
Risk of MS based on family history
```
1 in 67 if one affected parent
20% if both parents affected or monozygotic twin
10% if one parent and one sibling
5% if dizygotic twin
2.7% if one affected sibling
```
58
What are the types of MS and which are most common?
85% is relapsing and remitting
10-15% primary progressive
Secondary progressive
59
Effect of pregnancy on MS relapses
- Less likely to relapse during pregnancy
- 20-30% relapse rate in 3-4m postpartum
- Relapses occur less often in parous women
- Pregnancy after MS onset associated with lower risk of progression
Overall pregnancy does not alter risk of MS or long term progression.
60
Epidural in MS?
Can do! No effect on risk of relapse.
61
Breastfeeding in MS?
Yes! Beneficial - reduces risk of relapse 3 x
62
Effect of MS on fertility/reproduction
No effect on fertility although lower AMH
Higher frequency of voluntary childlessness and TOP (20% v 12%)
ART (particularly unsuccessful attempts or agonist protocols) associated with increased relapse rate of 7 x in the 3/12 following.
63
Percentage of women with MS with sexual dysfunction
30-70%
64
Effect of MS on miscarriage, stillbirth, congenital abnormality, perinatal mortality, antenatal hospital admissions, CS and instrumental delivery?
None of the fetal risks are increased.
| Antenatal admission, CS and instrumental are increased.
65
Effect of MS on PTB
Increased
66
Effect of MS on FGR
1.7 x increased risk
67
Which drugs can be continued until conception?
Interferon and glatiramer
68
Which drugs can be used in pregnancy?
Steroids
Some women with severe disease may continue natalizumab which crosses placenta after 2nd trimester and can cause SGA/haematological abnormalities (but not miscarriage/congenital abnormalities).
69
Growth scans in MS?
Yes please
70
Mode of delivery in MS
Vaginal delivery safe
| If severe neurological problems likely planned CS
71
Lifetime risk of stroke
1/6
72
Incidence of stroke in pregnancy (and compare rate to general population)
30 in 100,000 (3 x compared to normal population)
73
When do the majority of strokes in pregnancy occur?
90% peripartum or in 6 weeks postpartum
74
Mortality associated with stroke in pregnancy
10-20% (14% haemorrhage, 3% ischaemic)
75
Residual disability associated with stroke in pregnancy
50% Haemorrhagic
| 33% Ischaemic
76
What percentage of strokes are ischaemic/haemorrhagic/venous thrombus?
1/3 for each
77
Which symptoms are more common with haemorrhage stroke?
Headache, reduced consciousness, nausea & vomiting
78
Investigations for stroke in pregnancy
Imaging:
- MRI first line in pregnancy if QUICK
- If not quick, non-contrast CT scan (5% background radiation for fetus - not a concern)
- CT angiogram for occlusions
Detecting cause:
- ECG/24h tape
- Echo
- Doppler of carotid and vertebral artery
- Consider thrombophilia screening
79
Management of ischaemic stroke in pregnancy
Intravenous thrombolysis (recombinant tissue plasminogen activator)
- pregnancy relative contraindication
- major surgery in last 2/52 relative contraindication
80
What is the risk of haemorrhage transformations after thrombolysis for ischaemic stroke?
2-6%
81
Treatment of haemorrhagic stroke
Haemostasis
Correction of coagulopathy
BP control
VTE prevention
82
What proportion of strokes are recurrent strokes?
25-30%
83
Mode of delivery after stroke
No evidence that CS safer
84
Risk of stroke recurrence
2% in future pregnancy
0.5% outside of pregnancy
In presence of thrombophilia 20%
85
Incidence of cerebral venous thrombosis
1 in 5000
86
Greatest risk of CVT
3rd trimester to 4 weeks postpartum
87
Presentation of CVT
Headache, papilloedema, focal neurological deficits, reduced consciousness, seizures
88
Diagnosis of CVT
MRI
89
Treatment of CVT
Anticoagulation 6 months
| Follow up MRI after 6 months
90
Most common site for CVT
Sagittal sinus with extension into cortical veins or primary thrombosis of cortical veins.
91
Most common prodromal symptom prior to seizure in PET
Headache
92
What percentage of headaches are migraine or tension?
>90%
93
Effect of pregnancy on idiopathic intracranial hypertension
Worsens during pregnancy
94
Describe the headache of IIH
- Throbbing, retrobulbar
- Worse with coughing/straining
- Worse with eye movements
- Associated visual disturbances, diplopia
- Associated N/V
- Papilloedema
- Visual field defect with enlarged blind spot
- 10% pseudo-localising sign of sixth nerve palsy (can't look out)
95
Diagnosis of IIH
Abnormally elevated CSF pressure (>25cmH20) with normal CSF constituents measured in lateral position.
96
Treatment of idiopathic intracranial hypertension
```
Monitor visual fields and acuity
Limit weight gain
Therapeutic LP
Acetazolamide
(Can use loop diuretics, avoid thiazide diuretics, can use steroids, can consider surgical/shunts)
```
97
In what percentage of epidurals does a dural puncture occur?
0.5-2.5%
98
If dural puncture occurs, what is likelihood of headache?
70-80%
99
Describe the headache of dural puncture
Fronto-occipital into neck, worse on standing and occurring 24-48h postpartum.
100
How long does dural puncture headache last if managed conservatively?
7-10d but can be up to 6 weeks
101
Cure rate with epidural blood patch
60-90%
102
When does posterior reversible encephalopathy syndrome (PRES) occur?
In association with PET
103
Headache of PRES
Headache, vomiting, visual disturbances, seizures and altered mental state.
104
Radiological findings in PRES
Oedema posterior circulation of brain
105
Management of PRES
As for severe PET
106
Headache associated with reversible cerebral vasoconstriction syndrome
Recurrent severe sudden onset headaches over period of 1-3 weeks. Often with nausea/vomiting/photophobia/confusion/blurred vision.
107
When does reversible cerebral vasoconstriction syndrome occur?
Postpartum period
108
Imaging findings in reversible cerebral vasoconstriction syndrome
Diffuse arterial beading on angiography with resolution over 1-3 months
109
Effect of pregnancy on migraines
Usually reduces frequency and severity
110
Management of migraine
Analgesia, anti-emetics.
2nd line sumatriptan.
Prophylaxis: Propranolol or low dose amitryptiline.
111
Increased risk of PET in patients with migraine
2 x
112
Which women improve/worsen/stable with MG in pregnancy?
40% worsen, 30% stable, 30% improve.
113
When are MG relapses most common?
First trimester or postpartum
114
Effect of MG on obstetric outcomes
None! No increase in risk of miscarriage, PET, CS, FGR or PTB.
115
Effect of MG on labour
Doesn't affect first stage may affect 2nd stage.
116
Mode of delivery for MG
Vaginal delivery recommended
117
Epidural for MG
Yes, recommended (avoid GA and opiates)
118
Risk of transient neonatal MG from antibodies
10-30%
119
What drug can't you have with MG in PTL?
Magnesium
120
Treatment for MG
Pyridostigmine (anti-cholinesterase inhibitor)
Steroids
Tacrolimus/ciclosporin
IVIG or plasmapheresis if acute crisis
121
When does neonatal MG present and resolve?
Presents within 4d and resolved within 4 weeks
122
What percentage of patients with MG have thymoma?
15%
123
Baseline investigations for patient with MG
Baseline motor strength
Pulmonary function
ECG
Thyroid function
124
Proportion of patients with MG with thyroid dysfunction
10-15%
125
Incidence of Bells palsy
45 in 100000
126
When does Bells palsy occur?
3rd trimester or immediate postpartum
127
Increase in risk of Bells palsy with PIH/PET
4 x more likely
128
Treatment of Bells palsy
Steroids if within 72h of onset
129
How common is Carpal tunnel?
25%
130
What proportion of women with Carpal tunnel have bilateral symptoms?
75%
131
What percentage of women with Carpal tunnel have residual symptoms postnatally?
15%
132
Treatment of Carpal tunnel
Wrist splints
| Local steroid injection
133
What causes paraesthesia meralgia?
Stretching and compression lateral femoral cutaneous nerve under inguinal ligament.
Occurs third trimester but can be precipitated by protracted labour. Sx exaggerated by standing/walking.
